Trends and sociodemographic inequalities in the use of caesarean section in Indonesia, 1987-2017

Abstract

IntroductionCaesarean section (CS) rates are increasing globally. CS can be a live-saving procedure when medically indicated, but it comes with higher risks for women and newborns when done without medical indication. Crucially, inequalities in who receives CS exist, both within and across countries. Understanding factors driving increasing rates and inequalities of CS is imperative to optimise the use of this life-saving intervention. This study aimed to investigate trends of CS use and inequalities across sociodemographic characteristics in Indonesia over a 30-year period.MethodsSeven waves of the Indonesia Demographic and Health Survey were used to estimate trends and inequalities in CS from 1987 to 2017. Relative and absolute inequalities across a range of sociodemographic characteristics were estimated and trends in inequalities were assessed through changes in rate ratio and rate difference.ResultsThe proportion of facility-based births in Indonesia has increased in the past 30 years, coinciding with an increase in CS rate (CSR) (1991 CSR: 1.6% (95% CI 1.3 to 1.9); 2017 CSR: 17.6% (95% CI 16.7 to 18.5)). Higher rates of CS are observed mostly in Western Indonesia, while lower CSRs are observed in Eastern Indonesia. Inequalities of CSRs in Indonesia are observed across type of health facility (public/private), regions, places of residence, wealth quintiles and maternal education, with the highest CSRs in more affluent and educated groups. Widening absolute inequalities of CS are observed across all sociodemographic characteristics, except facility type, where CSR gaps between public and private facilities have closed on both relative and absolute scales.ConclusionThis study provides evidence of increasing trends in CSRs and widening absolute inequalities in CSRs across different sociodemographic groups of women in Indonesia. The context of increasing CSRs across society, however, may have resulted in more stable relative inequalities. Improving understanding of the drivers of these trends in Indonesia and, particularly, of women’s and providers’ perspectives and preferences for childbirth, should be prioritised to optimise the use of CS.

Assessing geographical and economic inequalities in caesarean section rates between the districts of Bihar, India: a secondary analysis of the National Family Health Survey

“…This scheme is similar to Indonesia’s social health insurance programme, Jamkesmas, for poor and near-poor people, which has been shown to improve access and reduce financial barriers. 28 In Bhutan, only small differences in caesarean section rates between wealth quintiles have been observed, with around one in eight of all deliveries by caesarean section. However, no privatisation of healthcare exists in this LMIC.…”

“…Cambodia has identified and targeted the poor for user fee exemptions and health insurance provision through health equity funds. This scheme is similar to Indonesia’s social health insurance programme, Jamkesmas, for poor and near-poor people, which has been shown to improve access and reduce financial barriers 28. In Bhutan, only small differences in caesarean section rates between wealth quintiles have been observed, with around one in eight of all deliveries by caesarean section.…”

Achieving WHO's Goal for Reducing Cesarean Section Rate in a Chinese Hospital

“…The CS can increase the comorbidity risks for women and newborns when done without medical indication, and nonindicated CS accounted for the majority of cesarean deliveries (19,20). Avoiding medically unnecessary CS operations is the effective method to control the high CS rate (20).…”

“…In contrast, the department director of Dongguan hospital responded to the call of the state to reduce CS through group meetings and communications, and took no more other administrative actions. The CS can increase the comorbidity risks for women and newborns when done without medical indication, and non-indicated CS accounted for the majority of cesarean deliveries ( 19 , 20 ). Avoiding medically unnecessary CS operations is the effective method to control the high CS rate ( 20 ).…”

Caesarean Section in Indonesia: Analysis of Trends and Socio-Demographic Correlates in Three Demographic and Health Surveys (2007–2017)

“…Caesarean section (C-section) has been a major public health concern worldwide in the recent past, because of its overuse and associated complications during and after surgery [1]. C-section was introduced as a clinical practice to save both mothers' and babies' lives when critical medical complications arise during pregnancy [2,3]. However, in the past 2 decades, the rate of childbirth through C-section has increased worldwide [3], to 40.5% in Latin America and the Caribbean, 32.3% in North America, 31.1% in Oceania, 25% in Europe, 19.1% in Asia and 7.3% in Africa [4,5].…”